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Objective: This study aims to assess the product performance of a new moldable peristomal adhesive with corresponding heating pad designed to facilitate and improve automatic speaking valve (ASV) fixation for hands-free speech in laryngectomized patients. Methods: Twenty laryngectomized patients, all regular adhesive users with prior ASV experience, were included. Study-specific questionnaires were used for data collection at baseline and after two weeks of moldable adhesive use. The primary outcome parameters were adhesive lifetime during hands-free speech, use and duration of hands-free speech, and patient preference. Additional outcome parameters were satisfaction, comfort, fit, and usability. Results: The moldable adhesive enabled ASV fixation adequate for hands-free speech in the majority of participants. Overall, the moldable adhesive significantly increased adhesive lifetime and duration of hands-free speech compared to participants' baseline adhesives (p < 0.05), regardless of stoma depth, skin irritation, or regular use of hands-free speech at baseline. The participants who preferred the moldable adhesive (55% of participants) experienced a significant increase in the adhesive lifetime (median of 24 h, range 8–144 h) and improved comfort, fit, and ease of speech. Conclusion: The moldable adhesive's lifetime and functional aspects, including the ease of use and custom fit, are encouraging outcomes and enable more laryngectomized patients to use hands-free speech more regularly. Level of Evidence: 4 Laryngoscope, 2023.

Total Laryngectomy seriously affects on patients Quality of Life and on their psychological well-being. The aim of this study was to verify the effects of pre-operative Speech-Language Pathology counselling on laryngectomized patients. Pilot randomized controlled trial. Twenty-seven patients undergoing total laryngectomy and primary tracheoesophageal puncture were randomized as follows: 14/27 subjects were collocated in the Experimental group who received preoperative Speech-Language Pathology counselling and 13/27 in the Control group group that did not receive it. Two interviews and four questionnaires (Psychological Distress Inventory, Impact of Event Scale-Revised, Hospital Anxiety and Depression Scale, Italian-Self-Evaluation of Communication Experiences after Laryngeal Cancer) were administered immediately after surgery (T0), 1- (T1) and 3-months (T2) after hospital discharge in order to asses levels of distress, post-traumatic stress and anxious-depressive symptoms, acquisition and acceptance of the new voice. Student’s t test and chi square test showed that the two groups of patients were equivalent. Experimental group was more satisfied with the information and obtained statistically better (p

Approccio multidisciplinare alla giunzione cranio vertebrale. Cenni storici, attuali orientamenti e prospettive future nell’alleanza tra neurochirurgia ed otorinolaringoiatria.Storicamente considerata “terra di nessuno”, la regione della giunzione cranio-vertebrale, così come la chirurgia di questa sede, hanno guadagnato altissima considerazione negli anni recenti per la complessità anatomica, funzionale e tecnica. La gestione multidisciplinare e l’alleanza tra neurochirurghi e otorinolaringoiatri anche in questo ambito è diventata sempre più forte negli anni. La giunzione cranio-vertebrale ha una architettura anatomica ossea, neurovascolare e muscolare unica e complessa in quanto non solo separa e congiunge il cranio con il rachide cervicale, ma presenta pattern speciali di flessione, estensione e rotazione assiale. La stabilità è garantita da una complessa combinazione di supporti ossei e ligamentosi, che consentono ampi gradi di motilità. La conoscenza dell’anatomia e della fisiologia della giunzione cranio-vertebrale consente di comprendere meglio le procedure chirurgiche e le patologie specifiche che interessano questa regione anatomica. Sebbene siano passati anni dell’inizio della chirurgia pioneristica di questa regione, le lesioni situate nella porzione anteriore della giunzione cranio-vertebrale rimangono ancora una stimolante sfida per il neurochirurgo. Molti studi sono presenti in letteratura con l’intento di esaminare l’anatomia microchirurgica delle porzioni anteriori, posteriori, extra e intradurali della giunzione cranio-vertebrale, così come le differenze e tutte le possibili vie di approccio a 360° per esporre al meglio e trattare patologie di questa regione. In questa revisione verrà effettuata una disamina sullo stato dell’arte in tale chirurgia, partendo dall’esperienza personale, dalle pubblicazioni e dalla letteratura più recente, al fine di sottolineare quando la collaborazione multidisciplinare sia fondamentale, altamente consigliata o non strettamente necessaria nella gestione delle patologie della regione cranio-vertebrale.Historically considered as a nobody’s land, craniovertebral junction (CVJ) surgery or specialty recently gained high consideration as symbol of challenging surgery as well as selective top level qualifying surgery. The alliance between Neurosurgeons and Otorhinolaringologists has become stronger in the time. CVJ has unique anatomical bone and neurovascular structures architecture. It not only separates from the subaxial cervical spine but it also provides a special cranial flexion, extension, and axial rotation pattern. Stability is provided by a complex combination of osseous and ligamentous supports which allows a large degree of motion. The perfect knowledge of CVJ anatomy and physiology allows to better understand surgical procedures of the occiput, atlas and axis and the specific diseases that affect the region. Although many years passed since the beginning of this pioneering surgery, managing lesions situated in the anterior aspect of the CVJ still remains a challenging neurosurgical problem. Many studies are available in the literature so far aiming to examine the microsurgical anatomy of both the anterior and posterior extradural and intradural aspects of the CVJ as well as the differences in all the possible surgical exposures obtained by 360° approach philosophy. Herein we provide a short but quite complete at glance tour across the personal experience and publications and the more recent literature available in order to highlight where this alliance between Neurosurgeon and Otorhinolaringologist is mandatory, strongly advisable or unnecessary.

A 75-year-old woman had an occasional finding of a left tonsil mass for dysphagia, which resulted a high-grade squamous carcinoma. Therefore, the patient was sent to have a left pharyngectomy. After the pharyngectomy, the patient reported persistent swallowing disorders and nasal reflux. Consequently, she had an oropharyngoesophageal scintigraphy, demonstrating irregular oral and pharyngeal swallowing phases and confirming reflux episodes into the rhinopharynx and into the oropharynx. In line with these findings, the patient was send to rehabilitation; the abnormal functional mechanisms, previously identified by the scintigraphy, allowed to guide the speech therapy, with a progressive clinical improvement.

Approccio multidisciplinare ai tumori maligni del vestibolo del naso: verso la definizione di nuovi standard.I tumori maligni del vestibolo del naso, principalmente SCC, sono considerati neoplasie rare. Nel presente lavoro, rivediamo lo stato attuale dell’arte per quanto riguarda la classificazione e il trattamento, e descriviamo le evidenze attuali a supporto di un cambiamento di paradigma. Nell’attuale classificazione AJCC il vestibolo del naso è considerato parte della cavità nasale/etmoide. Nella pratica clinica quotidiana, le lesioni del vestibolo del naso sono spesso erroneamente classificate come primarie della pelle. Questo porta a una sottovalutazione della reale incidenza e a una cattiva gestione. Quando i tumori primitivi del vestibolo del naso sono correttamente classificati come a origine dal naso/seni paranasali, l’attuale AJCC TNM appare inadeguato per la stratificazione prognostica e un vecchio sistema di stadiazione descritto 4 decenni fa da Wang ha dimostrato di essere più affidabile ed è preferito nei centri con il maggior volume di casi trattati. I principi della classificazione di Wang dovrebbero essere applicati e il vestibolo del naso dovrebbe essere riconosciuto dall’AJCC/UICC come una nuova sottosede distinta di naso e seni paranasali. La chirurgia, la radioterapia a fasci esterni (EBRT) e la radioterapia interventistica (IRT, BrachyTherapy BT) sono le attuali opzioni terapeutiche per il carcinoma del vestibolo del naso (NVSCC). Sempre più evidenze dimostrano che la IRT, da effettuarsi in un contesto rigorosamente multidisciplinare, è almeno equivalente alla chirurgia e all’EBRT per il trattamento delle lesioni primarie in termini di esiti oncologici, ma nettamente superiore in termini di risultati estetici e funzionali, supportando l’HDR (high dose rate) IRT come nuovo standard per il trattamento della lesione primaria in questi tumori maligni. Per ottimizzare i vantaggi della IRT come modalità terapeutica primaria abbiamo impostato un nuovo approccio alla fase di impianto della IRT sfruttando i piani anatomici della chirurgia estetica e funzionale del naso e le potenzialità della brachiterapia a intensità modulata e guidata dalle immagini, per evitare la perforazione del setto e dell’ala (impianto anatomico).Nose vestibule malignancies, mainly SCCs, are considered rare neoplasms. In the present paper, we review the current state of the art concerning classification and treatment, and describe current evidence supporting a paradigm shift. In the current AJCC classification nose vestibule is considered part of nasal cavity/ethmoid. In daily clinical practice, nose vestibule lesions are often misclassified as skin primaries. This leads to an underestimation of the real incidence and to a mis-management. When nose vestibule primaries are correctly classified as nose primaries, the current AJCC TNM appears inadequate for prognostic stratification and an old staging system described 4 decades ago by Wang has been demonstrated to be more reliable in the literature and is preferred in centers with the largest volume of cases treated. The principles of Wang classification should be applied and nose vestibule acknowledged as a new distinct subsite of nose and paranasal sinuses by the AJCC/UICC. Surgery, External Beam RadioTherapy (EBRT) and Interventional RadioTherapy (IRT, BrachyTherapy BT) are the current therapeutic options for nose vestibule (NV) SCC.Increasing evidence demonstrates that IRT, with a proper multidisciplinary approach, is at least equivalent to surgery and EBRT for treatment of the primary lesions in terms of oncological outcomes, but markedly superior in terms of cosmetic and functional results, supporting HDR (high dose rate) IRT as the new standard for the treatment of the primary lesion in these malignancies. To optimize the advantages of IRT as primary therapeutic modality we set up a new approach to the implantation phase of IRT exploiting the anatomic planes of esthetic and functional nose surgery and the potential of intensity modulated and image guided brachytherapy to avoid septal and alar perforation (anatomic implantation).

L’approccio multidisciplinare alla decompressione orbitaria. Una review.La chirurgia endoscopica orbitaria rappresenta un ambito multidisciplinare in costante evoluzione grazie allo sviluppo delle tecniche sia in ambito oftalmologico che otorinolaringoiatrico. Tali progressi hanno esteso le applicazioni cliniche della decompressione orbitaria, con incremento del numero di lavori in letteratura, volti a descrivere la gestione multidisciplinare dell’orbitopatia tiroidea e della neuropatia ottica compressiva, a partire dagli anni ’90. Sebbene le tecniche si siano evolute notevolmente, solo pochi studi controllati randomizzati mostrano evidenze a supporto di indicazioni per la pratica clinica. Questa review fornisce una panoramica delle conoscenze attuali sulla decompressione orbitaria, per chiarire quali siano le strategie terapeutiche maggiormente standardizzate. In letteratura, abbiamo osservato i diversi approcci con risultati contrastanti e il confronto delle varie tecniche chirurgiche è influenzato dall’inclusione di pazienti in stadio di malattia differente (fase attiva o inattiva), da differenti indicazioni alla chirurgia (neuropatia distiroidea o proptosi sfigurante) e metodi di misurazione dei risultati (come ad esempio vari sistemi per la valutazione della motilità oculare). La tempistica della decompressione chirurgica è un altro dei temi ancora oggi dibattuti. Uno studio clinico randomizzato ha mostrato come la terapia steroidea endovenosa consenta un miglior recupero visivo rispetto alla decompressione orbitaria chirurgica; ma in caso di scarsa risposta alla terapia medica il paziente dovrebbe essere sottoposto a chirurgia entro due settimane. C’è una lieve evidenza che la rimozione delle pareti mediale e laterale (cosiddetta decompressione bilanciata) con o senza rimozione del grasso orbitario rappresenti la tecnica chirurgica più efficace, con un basso tasso di complicanze. La decompressione a tre pareti è scelta in caso di proptosi di alto grado, ma le complicanze sono più frequenti. Un numero crescente di autori sta promuovendo, per casi selezionati, un approccio chirurgico puramente endoscopico (con rimozione della parete orbitaria mediale e infero-mediale), meno invasivo della decompressione bilanciata; quest’ultima appare indicata nei casi di proptosi più grave o di diplopia post-procedura endoscopica. La corretta tempistica della decompressione orbitaria è ancora da determinare, soprattutto se presente una concomitante neuropatia ottica. Procedure aggiuntive oftalmologiche sono necessarie per la normale funzionalità e cosmesi. La chirurgia dello strabismo per correggere la diplopia e l’abbassamento della posizione della palpebra superiore rappresentano alcuni dei passaggi successivi per la riabilitazione finale dell’orbitopatia di Graves. I principali outcome attualmente valutati includono acuità visiva, proptosi e diplopia di nuova insorgenza. Studi recenti si focalizzano sullo sviluppo di misurazioni sull’imaging per valutare i risultati chirurgici e i questionari sulla qualità della vita stanno acquisendo importanza sempre maggiore.Endoscopic orbital surgery has become a highly evolving multidisciplinary surgical field thanks to development in technical skills of ophthalmologists and otolaryngologists. These advances expanded the clinical application of orbital decompression, with a growing body of literature describing the multidisciplinary management of thyroid eye disease and compressive optic neuropathy, since 1990. Although techniques have improved considerably, only few Randomized Control Trials (RCT) provide evidence to support recommendations in clinical practice. This review provides an overview of the current knowledge of orbital decompression to clarify which is the most standardized therapeutic strategy. In the literature, we observed several approaches with contradicting results and the comparison of different surgical techniques was biased by inclusion of patients at different stage of disease (active or inactive), different surgical indications (dysthyroid neuropathy or disfiguring proptosis) and measures of outcomes (such as different system for ocular motility evaluation). The timing of surgical decompression is one of the debated issues. One RCT focusing on Graves’ orbitopathy showed how intravenous corticosteroids achieve better visual recovery than surgical orbital decompression; but in case of absent or poor response to medical therapy the patient should undergo surgery within two weeks. There is slight evidence that the removal of the medial and lateral wall (so-called balanced decompression) with or without fat removal could be the most effective surgical technique, with low complication rate, but an increasing number of authors are promoting, for selected cases, a pure endoscopic surgical approach (with removal of medial and infero-medial orbital wall), less invasive than the balanced one; the latter indicated to more severe proptosis or diplopia after endoscopic procedure. Three-wall decompression is chosen for high degrees of proptosis, but complications are more frequent. Timing of surgical orbital decompression, in particular when a concomitant optic neuropathy is present, is still to be determined. Additional ophthalmological procedures are needed to restore normal eye function and cosmesis. Strabismus surgery to address diplopia and lowering the position of the upper eyelid represent some of the additional steps for the final rehabilitation of Graves’ orbitopathy. The main clinical outcomes including visual acuity, proptosis, and new-onset diplopia are changing. Recent studies focused on the development of imaging measurements in order to objectively evaluate the surgical results and QOL questionnaires are gaining increasing importance.

ObjectivePeriprosthetic leakage represents the most demanding long-term complication in the voice prosthesis rehabilitation. The aim of this article is to discuss the various causes of periprosthet...

Purpose The aim of this paper was to evaluate treatment outcomes following interventional radiotherapy (brachytherapy - BT) for nasal vestibule cancer. Material and methods Considering histological diagnosis and staging, a multidisciplinary tumor board indicated an exclusive interventional radiotherapy for all patients. Plastic tubes were placed mainly with interstitial approach. The total dose was 44 Gy in 14 fractions, 3 Gy/fraction (except for the first and last fractions, 4 Gy), 2 fractions per day (b.i.d.), 5 days a week. Inclusion criteria for this analysis were: patients affected by squamous cell carcinoma with follow-up more than 6 months. Results 20 patients with primary nasal vestibule cancer were treated with IRT from May 2012 to June 2019. We excluded 4 patients due to follow-up less than 6 months and 2 patients affected by basal cell carcinoma. In total, 14 consecutive previously untreated patients were considered for definitive analysis, median age was 67.5 (range, 51-83) years, median follow-up was 53 (range, 6-84) months. All patients followed the protocol except one, who received a total dose of 42 Gy in 12 fractions, 3 Gy per 6 fractions, and 4 Gy per 6 fractions. Local control at 12, 24, and 36 months was 85.7%. Overall survival at 12 months was 92.3%, at 24 months was 76.9%, and at 36 months was 69.2%. Staging system proposed by Wang was statistically significant on local control (LC), disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS). Excellent cosmetic results were observed. Conclusions This study confirms that interventional radiotherapy could be considered as a definitive treatment in nasal vestibule cancer with excellent oncological and cosmetic outcomes.

Marker di staminalità nei carcinomi squamocellulari del cavo orale e orofaringe in relazione al sito di origine e a infezione da HPV: implicazioni cliniche.In questo studio è stata esaminata l’espressione di potenziali marcatori di staminalità nei carcinomi della testa e collo (HNSCC) per valutarne il loro possibile ruolo clinico. Sono stati arruolati 69 carcinomi squamocellulari del cavo orale (OSCC) e dell’orofaringe (OPSCC) primitivi e non precedentemente sottoposti a trattamento, raccogliendo i dati anagrafici, clinici e sul follow up. Abbiamo valutato l’eventuale infezione da HPV e l’espressione di 5 potenziali marker di staminalità (CD44, CD133, Oct-4, Nanog, and Sox-2). Gli OPSCC positivi per HPV hanno mostrato minor espressione di Nanog, mentre la sua espressione citoplasmatica è stata associata con una prognosi significativamente peggiore negli OPSCC ma non in OSCC. La colorazione di Sox-2 si è rivelata più intensa tra gli OPSCC, e la sua espressione nucleare è associata con una peggiore prognosi. L’espressione di Nanog è associata a OPSCC HPV-negativi e può avere un ruolo come marker diagnostico surrogato. In conclusione il profilo di espressione di alcuni marker di cellule staminali nei HNSCC sembra essere differente a seconda del sito di origine del tumore e dell’infezione da HPV. Inoltre Nanog e Sox-2 potrebbero presentare un significato prognostico.The expression of potential stem cell markers in HNSCCs was investigated to assess their potential clinical role. 69 primary, previously untreated oral (OSCC) and oropharyngeal squamous cell carcinomas (OPSCC) were enrolled; personal, clinical and follow-up data were collected. HPV infection and expression of 5 potential stem cell markers (CD44, CD133, Oct-4, Nanog, and Sox-2) were evaluated. HPV+ OPSCC showed lower expression of Nanog. The cytoplasmic expression of Nanog was associated with significantly worse prognosis in OPSCC, but not in OSCC. Sox-2 staining was more intense among OPSCCs. Sox-2 nuclear staining was associated with worse prognosis. Nanog expression was associated with HPV- OPSCC and may have a role as a surrogate diagnostic marker. In general, the expression profile of some stem cell markers in HNSCC seems to vary according to the site of origin and HPV infection. Nanog and Sox-2 may also have prognostic value.

To evaluate the effects of new devices-heat and moisture exchangers (HMEs) and adhesives-on pulmonary symptoms, subject adherence, quality of life, dermatologic symptoms, and patient satisfaction after laryngectomy.Prospective crossover study.Between December 2020 and April 2021, 40 patients were enrolled who had undergone laryngectomy, routinely used HMEs and adhesive, and were followed in our Department of Otolaryngology-Head and Neck Surgery.Patients were allocated into group A (new products) or group B (usual care) for 6 weeks. Then the 2 groups reversed, and each patient acted as his or her own control. Patients kept a diary and cough tally sheet. At baseline and after each 6-week period, 2 questionnaires were administered: EQ-5D (European Quality of Life-5 Dimensions) and CASA-Q (Cough and Sputum Assessment Questionnaire).Six weeks of using new products resulted in the following effects for both groups: (1) a significant reduction in daily forced expectoration and dry coughs, (2) a significant improvement in all domains of the CASA-Q, (3) an increase in adherence to HME use, (4) a significant reduction in shortness of breath and skin irritation, and (5) significantly better scores in the anxiety/depression domain of the EQ-5D.Achieving this reduction in patients who were already highly adherent to HME use is clinically relevant and underscores the importance of using better-performing HMEs that can compensate for the humidification deficit. Improving pulmonary symptomatology could reduce patient restrictions in daily life and avoidance of social activity, with a consequent positive effect on quality of life.

(1) Background: Periorificial face cancer (PFC), defined as both squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) arising around the eyelids, the nose vestibule and the lips, has very high incidence rates worldwide. The aim of our retrospective analysis, focusing on local control (LC) and patients’ degree of satisfaction with the cosmetic outcome, is to present the results of a single institutional series of patients affected by PFC and treated by interventional radiotherapy (brachytherapy–IRT). (2) Methods: We retrospectively evaluated patients affected by PFC who were treated at our Interventional Oncology Center (IOC) with interstitial IRT from 2012 to 2021 with doses and volumes specific for each subsite considered. (3) Results: We report the results of 40 patients affected by PFC and treated by HDR interstitial IRT. The median follow-up was 24 months. The actuarial 3-year LC was 94%. Regarding patients’ satisfaction, we found that 93% of patients were satisfied and only 7% of patients were not completely satisfied with the final cosmetic result. (4) Conclusions: Interstitial HDR IRT could be an effective therapeutic option providing adequate disease control and preventing potentially disfiguring surgical approaches. More numerous and standardized studies are warranted to confirm the available evidence.

Objectives: We aim to analyze long-term voice outcomes and Quality of Life (QoL) in patients undergoing Open Partial Horizontal Laryngectomy Type II (OPHL Type II) and to compare them to those obtained by patients undergoing Total Laryngectomy (TL) with voice prosthesis (VP). Design: Cross-sectional cohort study Setting: patients undergoing surgery for advanced laryngeal cancer, assessed during the usual follow-up consultations at the Phoniatric Unit (February 2020-December 2020). Participants: Forty-five patients were enrolled and divided into two groups: OPHL Group and TL Group. Main outcomes measures: Maximum phonation time, INFV0 scale, I-SECEL, UWQoL-V4 and MDADI questionnaires were used to assess the long-term outcomes. Results: Voices of patients undergoing OPHL Type II were worse than those of laryngectomized patients with VP. Nevertheless, scores in voice and dysphagia-related QoL were comparable and scores in the Social domain of QoL were better in OPHL group. Conclusions. OPHL Type II allows an acceptable voice recovery and a satisfactory QoL.

The role of elective neck dissection during salvage surgery in patients with a clinically negative neck (cN0) is still discussed. The main objective of this work was to estimate the prevalence and predictive factors of occult neck nodes metastasis; we therefore aimed to evaluate the survival rate and the main oncologic outcomes of cN0 patients who underwent salvage total laryngectomy and elective bilateral neck dissection. In this retrospective observational study, we enrolled 80 cN0 patients affected by recurrent laryngeal cancer and who underwent salvage total laryngectomy and bilateral selective elective neck dissection. Several parameters were collected in order to find prognostic factors; finally, postoperative complications were reviewed and survival analysis was performed. Occult lymph node metastases were reported in 18 out of 80 patients (22.5%). Significant statistical correlation between lymphovascular invasion (p = 0.007), perineural invasion (p = 0.025) and occult nodal metastasis was found. Other variables (glottic subsite of recurrence, clinical T, pathological T, previous chemotherapy) were not significantly predictive of occult nodal metastasis. The 5-year OS, DSS, and RFS were 50.4%, 64.7%, and 63.4%, respectively. In conclusion, our single-institution data on a large cohort of patients, suggest performing routinely elective selective bilateral neck dissection during salvage total laryngectomy in cN0 patients due to the biological attitude of the tumor to spread to cervical nodes, considering an acceptable complications rate.

Finestra di un anno sulla gestione di pazienti con protesi fonatoria. È un carico clinico sovrastimato?La gestione delle complicanze tardive rappresenta il motivo principale della riluttanza nell’uso della riabilitazione con protesi fonatoria dopo laringectomia totale. Lo scopo del presente lavoro è descrivere un anno di gestione di un’ampia coorte di pazienti, al fine di chiarire quanto impegnativo sia il management in termini di carico lavorativo per i clinici dedicati. Nel periodo compreso tra giugno 2017 e giugno 2018, ogni accesso effettuato, presso la Clinica di Otorinolaringoiatria del nostro Istituto, da 70 pazienti laringectomizzati riabilitati con protesi fonatoria per problematiche legate al dispositivo protesico, è stato registrato su uno specifico database. L’analisi dei dati ha fornito informazioni sull’incidenza, la gestione e gli outcomes relativi a tutti gli eventi avversi riscontrati durante il periodo preso in esame. Al fine di valutare le differenze tra pazienti irradiati e non irradiati e pazienti sottoposti a posizionamento simultaneo e sequenziale/ritardato è stato, inoltre, utilizzato il test T di Student. Il leakage intravalvolare è stata la causa di accesso più frequente (51,86%). Il numero medio di accessi per paziente per anno è stato pari a 3,47. La logopedista ha gestito autonomamente il 18,1% degli accessi. Di conseguenza, il numero medio di accessi per paziente per anno che hanno necessitato di visita medica è stato pari a 2,84. La durata media del dispositivo protesico è stata pari a 4,85 mesi. La radioterapia o la tecnica di posizionamento utilizzata (simultanea o sequenziale/ritardata) non ha influenzato il numero di accessi per anno né la durata della protesi fonatoria. L’analisi retrospettiva dei risultati ha evidenziato le problematiche più frequenti e le misure più efficaci per affrontarle, permettendo la creazione di un algoritmo sistematico che agevoli e standardizzi il management a lungo termine di questi pazienti.Management of late complications represents the main reason for reluctance in using voice prosthesis rehabilitation. The aim of this paper is to report our experience by describing the one-year management of a large cohort of patients in order to clarify how demanding management is in terms of burden on clinicians. Between June 2017 and June 2018, each access made at the Otolaryngology Clinic of our Institute for issues related to prosthesis by 70 laryngectomised patients rehabilitated by voice prosthesis was registered in a specific database. A review of the data provided information on the incidence, management and outcomes of adverse events encountered during the selected time frame. In addition, a T test was used to evaluate the differences between irradiated and non-irradiated patients and between primary and secondary tracheo-oesophageal-puncture. Leakage through the prosthesis was the most common cause for access (51.86%). The median number of accesses per patient per year was 3.47. The speech therapist autonomously managed 18.1% of accesses. The median number of accesses per patient per year needing a physician was 2.84. The median lifetime of the prosthesis was 4.85 months. Radiotherapy or modality (primary or secondary) of the puncture did not influence the number of accesses per year or the prosthesis lifetime. This retrospective analysis of results highlighted the most frequent issues and the most effective measures to deal with them, which allowed us to define a systematic algorithm to standardise and ease long-term outpatient management.

Background: Descending necrotizing mediastinitis (DNM) is a severe, life-threatening complication of oropharyngeal infections with cervical necrotizing fasciitis. In this study, we aimed to identify any possible factors that correlate with favorable outcomes. Methods: We retrospectively analyzed our series of 18 patients who underwent surgical treatment for DNM from a cervical abscess. Gender, age, symptoms, etiopathogenesis, comorbidities, time to surgery from diagnosis, degree of diffusion, identified microorganisms, surgical procedure, days in the intensive care unit, need for tracheostomy, complications, and surgical outcomes were reviewed. Results: The main type of surgery was thoracotomy + cervicotomy in eight cases (50.0%), followed by cervicotomy +VATS in four (22.2%). Seven patients (38.9%) had two or more surgeries; a bilateral operation was necessary for four patients. Evaluating the risk factors associated with post-operative complications, age ≥ 60 years (p:0.031), cervicotomy alone as surgical approach (p = 0.040), and the bilateral approach (p = 0.048) resulted in significance in terms of the univariate analysis; age ≥ 60 years (p = 0.04) and cervical approach (p = 0.05) maintained their significance in terms of the multivariate analysis. Conclusions: The low mortality of our series emphasizes the importance of an extensive and immediate surgical drainage of both the neck and the mediastinum. Mediastinal drainage from cervicotomy seems to be a risk factor for post-operative complications. Minimally invasive surgery on the chest cavity, such as with Uniportal-VATS, could be a good approach above all in elderly patients and all those cases where bilateral access is required.

Autologous tissue-assisted regenerative procedures have been considered effective to close different types of fistula, including the leakage around tracheoesophageal puncture. The aim of this study was to retrospectively review 10 years of lipotransfer for persistent periprosthetic leakage in laryngectomized patients with voice prosthesis. Clinical records of patients who experienced periprosthetic leakage from December 2009 to December 2019 were reviewed. Patients receiving fat grafting were included. The leakage around the prosthesis was assessed with a methylene blue test. Twenty patients experiencing tracheoesophageal fistula enlargement were treated with fat grafting. At the one-month follow-up, all patients were considered improved with no leakage observed. At six months, a single injection was sufficient to solve 75% of cases (n 15), whereas 25% (n 5) required a second procedure. The overall success rate was 80% (n 16). Results remained stable for a follow-up of 5.54 ± 3.97 years. Fat grafting performed around the voice prosthesis, thanks to its volumetric and regenerative properties, is a valid and lasting option to solve persistent periprosthetic leakage.

Nasopharyngeal (NP) and oropharyngeal (OP) specimens in the detection of the SARS-Cov-2 RNA are considered to have the highest diagnostic sensitivity and they have been recommended by the World Health Organization as the most reliable test. However, collecting NP specimens require specialized operators and adequate technique. We describe an intranasal breaking of the nasopharyngeal swab for anatomical reasons needing a surgical removing. We conclude that a safely procedure needs possibly a check for septal deviations or other causes of nasal obstruction.

Objective To describe a remote approach used with patients with voice prosthesis after laryngectomy during the COVID-19 pandemic and the resulting clinical outcomes in terms of voice prosthesis complications management, oncological monitoring, and psychophysical well-being. Study Design Prospective cohort study. Setting Otolaryngology Clinic of the University Polyclinic A. Gemelli, IRCCS Foundation. Subjects and Methods All patients with voice prosthesis who underwent laryngectomy followed by our institute were offered enrollment. Patients who agreed to participate were interviewed to inquire about the nature of the need and to plan a video call with the appropriate clinician. Before and 1 week after the clinician’s call, patients were tested with the Hospital Anxiety and Depression Scale. Degrees of satisfaction were investigated with a visual analog scale. A comparison between those who accepted and refused telematic support was carried out to identify factors that influence patient interest in teleservice. Results Video call service allowed us to reach 37 (50.68%) of 73 patients. In 23 (62.16%) of 37 cases, the video call was sufficient to manage the problem. In the remaining 14 cases (37.83%), an outpatient visit was necessary. Participants who refused telematic support had a significantly shorter time interval from the last ear, nose, and throat visit than patients who accepted (57.95 vs 96.14 days, P = .03). Video-called patients showed significantly decreased levels of anxiety and depression (mean Hospital Anxiety and Depression Scale total score pre– vs post–video call: 13.97 vs. 10.23, P < .0001) and reported high levels of satisfaction about the service. Conclusion Remote approach may be a viable support in the management of patients with voice prosthesis rehabilitation.

OBJECTIVES/HYPOTHESIS To analyze stapler benefits in salvage total laryngectomy in terms of surgical time, hospitalization length, oral feeding time, and occurrence of pharyngocutaneous fistula, and to evaluate risk factors for its onset. STUDY DESIGN Retrospective analysis. METHODS One hundred fourteen patients affected by endolaryngeal squamous cell carcinoma who underwent salvage total laryngectomy following primary treatment failure were reviewed. We divided patients into two groups based on type of pharyngeal suture performed: mechanical suture with stapler (group A) and manual suture (group B). These two groups were compared for surgical time, start of oral feeding, hospitalization length, surgical margins and pharyngocutaneous fistula incidence considering its relationship with diabetes mellitus, nutritional status, primary treatment, and neck dissection. RESULTS In group A and group B, oral feeding restarting time was 15 ± 9.33 versus 20.03 ± 13.81 days, hospitalization was 17.63 ± 10.08 versus 23.72 ± 14.29 days, and surgery lasted 268.39 ± 76.93 versus 294.26 ± 140.58 minutes, respectively (P

Functional and aesthetic results after septorhinoplasty (SRP) are often not clearly demonstrated. There is still an open topic in the literature about analysis of aesthetic, functional results and patients’ satisfaction after SRP. The aim of our study is to determine patients’ satisfaction after SRP and concomitant radiofrequency of the inferior turbinate (RF) regarding nose appearance and improvement of symptoms, using patient reported outcome measures (PROMs). ROE questionnaire and the NOSE scale were used for a retrospective evaluation to assess patient’s satisfaction in 369 patients undergoing SRP surgery from 2003 to 2016. Two additional questions were asked to confirm satisfaction following surgery. 258 patients completed the questionnaires (71.7%). The global average ROE score was 18.14 (75.6%). The percentage of satisfaction of aesthetic result was 87.3%, in particular 10.5% were very happy, 57% very much satisfied and 19.8% moderately satisfied. The global post-operative average NOSE score was 13.1 with the resolution of nasal obstruction in 72.1% cases and a marked improvement in 9.3%. The results of the two additional questions showed that 81% of patients would undergo the procedure again if required and 72.1% of patients were globally satisfied. Our study demonstrates the utility of PROMs in evaluating aesthetic and functional results after SRP and simultaneous RF. In our series, the patients undergoing SRP and RF are generally satisfied by the functional and aesthetic results. This kind of assessments should be the most common post-operative evaluation methods in this surgery.

Objective The objective of the study was to compare the biofilm growing pattern and its morphological extent on silicone and a teflon-like material using a sonication process and a Scanning Electron Microscope (SEM). Design A prospective cohort study and a laboratory study. Setting Otolaryngology -Head and Neck surgery Department and the Microbiology Institute. Participants The participants included fifteen laryngectomised patients with phonatory prostheses, which were removed because of device failure, and two different kinds of phonatory prostheses from the laboratory (Provox 2 and ActiValve) that were artificially colonised by Candida albicans. Main outcome measures Tracheo-oesophageal puncture (TEP) is currently considered the gold standard for post-laryngectomy voice rehabilitation. "Leakage" represents the most common cause of substitution and is generated by biofilm colonisation of the prosthesis by mixed mycotic and bacterial agents. New biomaterials have been developed that are deemed to be more resistant to the colonisation of micro-organisms and material deformation. Results The devices showed colonisation by mixed bacterial flora (Staphylococci 13%, Streptococci 9%, and Haemophilus influenzae 5%) and by yeasts (Candida albicans 12%). Moreover, we observed a different distribution of biofilm layers in Provox ActiValve (22.56%) compared to Provox 2 (56.82%) after experimental colonisation by the previously isolated Candida strain. Conclusion Resident microbiological species from the upper airways unavoidably colonise the polymer surfaces, and no strategies have been effective except for the manipulation of the chemical-physical properties of the device's polymer. Our study confirms that Provox ActiValve, which is made with a fluoroplastic material (teflon-like), is less subject to in vitro colonisation by Candida, and thus showed a higher clinical resistance to biofilm and a longer lifespan. The sonication seems to significantly improve the knowledge of bacterial and mycotic flora in biofilm colonisation. The design of a device for the daily cleaning capable to reach and brush the oesophageal flange of the prosthesis preserving the valve mechanism could represent a practical and simple help in this still unsolved problem.

Background: The aim of this study was to assess diagnostic accuracy and reliability of narrow band imaging (NBI) in the differential diagnosis of laryngeal premalignant lesion, early cancers and recurrences. Material and methods: We enrolled 231 patients who underwent endoscopic examination with white light endoscopy (WLE) + NBI and divided them into two groups, group A, without previous radiochemotherapy and group B, with previous radiochemotherapy. When indicated, we performed surgical biopsies to evaluate sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy and likelihood of endoscopic examination comparing WLE alone and WLE + NBI. Results: A positive NBI lesion, compared with a negative NBI lesion, had a 29.68 (group A) and 13.96 (group B) times higher probability to be histologically positive (i.e., confirmed) compared with WLE alone improving the diagnostic accuracy. In group A, the NBI mode showed excellent sensitivity (95.0%), which was higher than WLE 2 mode (77.5%). However, the greatest differences were recorded regarding specificity (96.8% vs. 40.6%). In group B, both NBI alone and WLE + NBI mode showed a 94.1% specificity compared with WLE alone, which had a maximum specificity of 85.3%. The mode comparison between NBI and WLE in both groups showed a statistically significant difference, with p-values &lt, 0.0001. Conclusions: NBI represents a reliable technology in challenging situations, especially in the context of post-radiotherapy or post-surgical mucosal changes showing a high NPV. NBI could reduce the number of unnecessary biopsies related to increased microvascular anomaly revelation, which could help to identify early-stage lesions suitable for minimally invasive surgery and, consequently, decrease hospital admissions.

BACKGROUND Interventional radiotherapy (brachytherapy; IRT) reemerged in the last decades as a potentially useful tool in head and neck oncology after a set of clear technical improvements were developed. METHODS Sixty-one high dose ratio (HDR) IRT treatments were recommended and performed on 58 patients. We classified the cases into four relatively homogeneous groups based on the clinical needs that led to the recommended IRT. Also, we separately evaluated primary and recurrent cases. RESULTS Disease-specific survival was significantly different among the four treatment groups. The group with the best prognosis was the cohort treated locally by exclusive interstitial IRT for resectable midface malignancies (2-year relapse-free survival = 82%, disease-specific survival = 89%). CONCLUSION HDR IRT is a valuable tool in well-defined clinical situations and, in particular, in recurrences. In midface malignancies, it could become the preferred primary treatment.

Acquisition and acceptance of the alaryngeal voice, psychological state, and Quality of Life (QoL) of laryngectomized patients. Thirty-two patients who underwent total laryngectomy were included in the study; 17 of them were treated by a psychologist and a speech therapist (experimental group); 15 performed only speech therapy (control group). The experimental group showed a significant improvement in all parameters of the INFVo scale, in the score of the Environment subscale and in the total score of the I-SECEL (Self-Evaluation of Communication Experiences after Laryngeal Cancer); in the Depression, Obsession-Compulsion and Paranoia areas of the SCL-90-R (Symptom Check List-90-Revised); and in the Social area (REL) of the WHOQOL-B (World Health Organization Quality of Life Scale–Brief). An integrated rehabilitative approach to laryngectomized patients improves emotional state and psychosocial aspects and promotes acceptance and use of the new voice and recovery of a better quality of life.

Background: Surgery is the first-line therapy for treatment of cutaneous squamous cell carcinoma (cSCC), and interventional radiotherapy is recommended when surgery is not feasible, contraindicated, or refused by the patient. Objectives: To provide a multidisciplinary systematic review of the role of interventional radiotherapy for the treatment of cSCC of the nasal vestibule. Materials and Methods: A systematic search was performed; primary outcomes were tumour local control and overall survival. Acute toxicity, late toxicity, and functional cosmetic results, regardless of the scoring systems used, were secondary outcomes. Results: After full-text reviewof the 92 papers initially identified, we included only 10 papers in the review; no randomized controlled trials or prospective studies were identified. Five studies reported five-year local control, with rates ranging between 69% and 97%. A high level of heterogeneity was observed regarding the methods used to assess treatment-related toxicity. Conclusion: Interventional radiotherapy may be considered for lesions specifically arising from the area of the nasal vestibule. A multidisciplinary approach might help to select cases that are potential candidates for conservative treatment according to the tumour and the patient’s features.

Obiettivo del presente studio è stato valutare i risultati oncologici della nostra casistica di pazienti affetti da tumore del cavo orale trattati mediante chirurgia compartimentale radicale seguita da ricostruzione mediante lembo microvascolare. Abbiamo condotto un’analisi retrospettiva su 130 casi. Tutti i pazienti sono stati sottoposti ad una resezione chirurgica della neoformazione seguita da una ricostruzione immediata mediante lembo libero e, quando necessario, in accordo con la valutazione espressa dal nostro tumor board e con le linee guida internazionali, ad un trattamento chemioradioterapico adjuvante. Le curve di sopravvivenza specifica per malattia (DSS) sono state ottenute mediante il metodo di Kaplan-Meier. Il test Long Rank e il Wilcoxon sono stati utilizzati per investigare i più importanti fattori influenzanti la sopravvivenza specifica per malattia a 5 anni. Per calcolare l’HR e il RR per le singole variabili è stato utilizzato un modello di Cox. L’88,5% dei pazienti è risultato affetto da una neoplasia a istologia squamocellulare. Il campione è risultato essere composto da 46 (35,4%) donne e 84 (64,6%) uomini con un età media di 58,5 anni. Al termine del periodo di follow up, 36 pazienti (27,7%) erano deceduti, 3 dei quali per altre cause. Il DSS è stato del 67,8% (S.E. = 4,9%). All’analisi univariata secondo Kaplan-Meier ed alla analisi multivariata con regressione di Cox sono state individuate sette differenti variabili aventi una relazione significativa con il DSS: T (p = 0,026) ed N (p = 0,0001), lo staging clinico (UICC TNM Sixth Edition) (p = 0,007), i margini di resezione (p = 0,001), l’extracapsular spread (p = 0.005), la recidiva di malattia (p = 0,00002) e la modalità di trattamento (sola chirurgia o chirurgia + RT/CHT) (p = 0,004). In nostri risultati sono risultati in linea con le osservazioni in letteratura, e ci permettono di sottolineare come la chirurgia ricostruttiva mediante lembo libero microvascolare possa incrementare la sopravvivenza nei pazienti con tumore del cavo orale.

La finalità del nostro lavoro è di valutare le caratteristiche di risonanza magnetica (RM) tipiche dei tumori parotidei maligni e benigni. Questo studio retrospettivo si basa sulla valutazione di esami RM pre-chirurgici di 94 pazienti con tumori parotidei. I risultati istologici erano disponibili in tutti i casi; abbiamo analizzato 69 lesioni erano benigne (73%) e 25 maligne (27%): 44 adenomi pleomorfi, 18 tumori di Warthin, 7 tumori benigni di diverso istotipo, 6 carcinomi squamocellulari, 3 carcinomi ex-adenomi pleomorfi, 2 carcinomi mucoepidermoidi, 1 tumore adenoidocistico, 13 tumori maligni di diverso istotipo. Sono state valutate le seguenti caratteristiche RM: morfologia, sede, dimensioni, margini, intensità di segnale nelle sequenze T2-pesate e T1-pesate, impregnazione dopo mezzo di contrasto (mdc), intensità di segnale della porzione cistica, presenza o assenza di una capsula, diffusione perineurale, pattern di crescita extraghiandolare e linfoadenopatie laterocervicali. È stata effettuata un’analisi statistica per identificare le caratteristiche RM più indicative di malignità e per definire l’aspetto tipico degli istotipi più comuni. I parametri significativamente predittivi di malignità sono risultati i margini mal-definiti (p < 0,001), le linfoadenopatie (p < 0,001) ed il pattern di crescita infiltrativo (p < 0,001). Le caratteristiche tipiche dell’adenoma pleomorfo sono risultate l’iperintensità di segnale nelle immagini T2-pesate (p = 0,02), l’intensa impregnazione dopo mdc (p < 0,001) ed i margini lobulati (p = 0,04). Le caratteristiche tipiche del tumore di Warthin sono risultate le componenti iperintense nelle immagini T1-pesate (p < 0,001), la localizzazione nel processo parotideo inferiore (p < 0,001) e l’impregnazione post-contrastografica lieve/incompleta (p = 0,01). L’intensità di segnale nelle immagini T1-pesate e T2- pesate e l’impregnazione post-contrastografica si sono rivelate utili nella diagnosi differenziale tra adenoma pleomorfo e tumore di Warthin.

Objectives/Hypothesis Squamous cell carcinoma arising from the nasal vestibule is a rare condition accounting for about 1% of head and neck malignancies with several peculiarities concerning both staging and treatment. The aim of this study was to compare the oncological and functional results of two different treatment modalities for the primary site: surgery and brachytherapy. Study Design A case series with the comparison of two different treatment modalities. Methods We evaluate clinical and survival data of 12 untreated patients, enrolled by a multidisciplinary tumor board, comparing oncological, functional, and esthetic results after surgery or after interstitial brachytherapy as exclusive treatments for the primary site. The functional and esthetic outcome was subjectively rated by the patients using a five-point scale. Results Locoregional control and survival are not significantly different between patients primarily treated by surgery and by brachytherapy. The functional and esthetic outcome, as assessed by the degree of satisfaction of the patients, is significantly better after primary brachytherapy than after primary surgery (P = .014). Conclusions In our experience brachytherapy, accomplished in close cooperation between surgeons and radiation oncologists, achieves oncological results that are not different from surgery, but with a higher degree of patient satisfaction, mainly due to the esthetic outcome. Level of Evidence 4 Laryngoscope, 2015

Background Several studies in the last decade evaluated conservative surgical procedures and, in particular, supracricoid operations as an alternative to total laryngectomy for the salvage of recurrences of laryngeal squamous cell carcinoma (SCC) after a first attempt of organ preservation. Methods The clinical records of 68 consecutive patients primarily treated by irradiation or endoscopic surgery and surgically salvaged by total laryngectomy or supracricoid partial laryngectomy in 2 large university hospitals in Italy from 2004 to 2010 were reviewed. Results The survival was not affected by the primary treatment or by salvage modality. The only parameter always keeping a prognostic value is the involvement of resection margins of salvage surgery. Patients with early relapse seem to have a worse prognosis than patients with a delayed relapse (p = .05 at Cox multivariate analysis and p = .048 at Wilcoxon test for overall survival [OS] from the primary treatment). Conclusion Supracricoid operations, if the indications are careful, can prove reliable salvage procedures. © 2014 Wiley Periodicals, Inc. Head Neck 37: 84–91, 2015

Olfactory neuroblastoma (ONB) is an uncommon neuroendocrine sinonasal cancer associated by many authors to ectopic production of several biologically active substances. We report a case of a 31-year-old male patient who presented with idiopathic syndrome of inappropriate secretion of antidiuretic hormone (SIADH). During diagnostic work-up, a CT scan of the head was performed and an ethmoidal ONB was detected. Endoscopical surgery followed by radiotherapy was carried out. Immediately after surgery natraemia levels normalised. Five years later the patient is disease-free. To our knowledge, 17 cases of SIADH associated to ONB have been published. In nine reports, idiopathic SIADH promptly led to the diagnosis of the sinonasal mass as in our clinical case, however, in many reports, correct diagnosis was accomplished months to years later. In young patients with idiopathic inappropriate antidiuretic hormone secretion, a neuroendocrine malignancy of the sinonasal area must be excluded.Il neuroblastoma olfattivo (ONB) è un raro tumore neuroendocrino dei seni paranasali associato, secondo molti autori, alla produzione di molteplici sostanze biologicamente attive. In questo lavoro descriviamo il caso di un paziente di sesso maschile di 31 anni giunto alla nostra osservazione presentando la sindrome idiopatica da inappropriata secrezione di ormone antidiuretico (SIADH). Durante il work-up diagnostico il paziente è stato sottoposto a TAC del massiccio facciale, che documentava la presenza di un estesioneuroblastoma etmoidale. è stato eseguito un trattamento di chirurgia endoscopica e successiva radioterapia. Subito dopo l’intervento chirurgico i livelli di natremia si sono normalizzati. Cinque anni più tardi il paziente risulta essere libero da malattia. Attualmente in letteratura sono stati pubblicati 17 casi di SIADH associata a ONB. In nove lavori la SIADH idiopatica ha tempestivamente portato alla diagnosi di masse sinusali come nel nostro caso, tuttavia, in molti casi, si è giunti alla diagnosi corretta mesi o anni dopo. Nei giovani pazienti con sindrome idiopatica da inappropriata secrezione di ormone antidiuretico è necessario escludere un tumore maligno neuroendocrino dei seni paranasali.

Nitric oxide (NO) is produced in the respiratory tract with a major contribution coming from paranasal sinuses and the nose. The pathophysiological role of NO in the airways has been debated. The aims of this study were to measure fraction of exhaled NO (FENO), a validated marker of airway inflammation, in patients affected by nasal polyposis with and without asthma; to assess the importance of FENO measurement in detecting subclinical involvement of lower airways in patients with clinical rhinosinusal symptoms; and to clarify the impact of endoscopic surgical removal of polyps on airway inflammation.The study was conducted at the O.R.L. Clinic and Clinical Pharmacology Unit, University Hospital Agostino Gemelli, Rome, Italy.Prospective study.Concentrations of FENO were measured with the NIOX system (Aerocrine, Stockholm, Sweden) by using a single-breath online method, according to the American Thoracic Society guidelines.Compared with those in healthy subjects (15 [11-19] ppb, n = 15; P.0001), FENO values were elevated in patients with nasal polyposis (41 [21-77] ppb, n = 43). There was no significant difference in FENO concentrations between asthmatic and nonasthmatic patients with nasal polyposis (P = .73). Concentrations of FENO in patients with nasal polyposis were decreased after surgery (64.2 [30.0-132.7] ppb vs 56.0 [26.4-73.8] ppb, respectively; P = .03).The fraction of exhaled NO is elevated in the inflammatory process involving both the rhinosinusal district and lower airways, supporting the one-airway disease hypothesis.

SUMMARY In this series of patients, the underlay or overlay positioning of a graft achieves successful outcome for both repair of perforation and hearing function, with better hearing gain in the underlay group. In myringoplasty, the two most common techniques for positioning the graft relative to the remnant of both the tympanic membrane and the annulus are the "overlay" and the "underlay" techniques. 115 patients who underwent myringoplasty for tympanic membrane perforation secondary to chronic otitis media and/or trauma were included, and hearing function was evaluated. We prefer an overlay technique in subtotal perforations, in those involving the anterior and antero-inferior parts of the ear drum with respect to the handle of the malleus and in revision surgery. We reserve an underlay technique for smaller perforations and for those limited to the posterior part of the tympanic membrane. Of 115 cases, 63 underwent an overlay myringoplasty and 52 underlay myringoplasty. In the former group, five cases were anatomically unsuccessful, whereas in the second group there were three failures. The air bone gap improved significantly in both groups with a better hearing gain in the underlay group.

SUMMARY Parotid gland tumours account for 80% of all salivary gland neoplasms, 20% of these are malignant, but in daily clinical practice most parotid masses are operated on before obtaining the final histological diagnosis. This clinical setting further complicates the critical point of parotid surgery, which is the management of the facial nerve. In the present study, data were evaluated referring to 540 patients who underwent parotidectomy for a mass which was discovered to be a benign (470 cases) or a malignant (70 cases) neoplasm, between November 1994 and December 2007, at our Institution. The most significant single parameter in this series of malignancies regarding disease specific survival was the clinical involvement of the facial nerve at diagnosis (p = 0.006). Also for this reason, as there is no evidence that liberal VIIth nerve sacrifice improves prognosis, when it is not clinically involved, every attempt is made to dissect and preserve it. At present, the most complicated situation concerning nerve preservation may be, on the other hand, recurrence of a benign tumour, in particular pleomorphic adenoma, which, in our series, has a higher incidence (8.3%) of permanent facial dysfunction, than surgery with nerve preservation for malignancy (3.7%).

Objective:To assess the electrode pitch function in a series of adults with postlingually implanted cochlear implants and with contralateral residual hearing, in order to investigate the correlation between the degree of frequency map mismatch and the subjects' speech understanding in quiet and noisy conditions.Design:Case series.Subjects:Seven postlingually deafened adults with cochlear implants, all with detectable contralateral residual hearing. Subjects' electrode pitch function was assessed by means of a pitch-matching test, in which they were asked to match an acoustic pitch (pure tones delivered to the non-implanted ear by an audiometer) to a perceived ‘pitch’ elicited by stimulation of the cochlear implant electrodes. A mismatch score was calculated for each subject. Speech recognition was tested using lists of sentences presented in quiet conditions and at +10, 0 and 5 dB HL signal-to-noise ratio levels (i.e. noise 10 dB HL lower than signal, noise as loud as signal and noise 5 dB HL higher than signal, respectively). Correlations were assessed using a linear regression model, with significance set at p Results:All patients presented some degree of mismatch between the acoustic frequencies assigned to their implant electrodes and the pitch elicited by stimulation of the same electrode, with high between-individual variability. A significant correlation (p r2 = 0.91 and 0.89, respectively).Conclusion:The mismatch between frequencies allocated to electrodes and the pitch perceived on stimulation of the same electrodes could partially account for our subjects' difficulties with speech understanding in noisy conditions. We suggest that these subjects could benefit from mismatch correction, through a procedure allowing individualised reallocation of frequency bands to electrodes.

Local gene transfer of the human LIM Mineralization Protein (LMP), a novel intracellular positive regulator of the osteoblast differentiation program, can induce efficient bone formation in rodents. In order to develop a clinically relevant gene therapy approach to facilitate bone healing, we have used primary dermal fibroblasts transduced ex vivo with Ad.LMP3 and seeded on an hydroxyapatite/collagen matrix prior to autologous implantation. Here we demonstrate that genetically modified autologous dermal fibroblasts expressing Ad.LMP-3 are able to induce ectopic bone formation following implantation of the matrix into the mouse triceps and paravertebral muscles. Moreover, implantation of the Ad.LMP-3-modified dermal fibroblasts into a rat mandibular bone critical size defect model results in efficient healing as determined by X-ray, histology and three dimensional micro computed tomography (3DμCT). These results demonstrate the effectiveness of the non-secreted intracellular osteogenic factor LMP-3, in inducing bone formation in vivo. Moreover, the utilization of autologous dermal fibroblasts implanted on a biomaterial represents a promising approach for possible future clinical applications aimed at inducing new bone formation.